Observation Care Documentation Requirements

According to the CPT, these codes apply to all assessment and management services provided by a practitioner on the same day as the start of the “compliance status”. (Note: Also use these codes for Medicare patients who spend 8 hours < observation) www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM4259.pdf Editor`s Note: This article is an excerpt from the Patient Condition Training Toolkit for Usage Review. For more information, see HCPro Healthcare Marketplace. To see the full excerpt from Medicare Insider, click here. The code of the procedure performed in the emergency room can be assigned in addition to the observation code. A -25 modifier may be added to the observation code, if necessary, to indicate a unique, separately identifiable service. CPT® describes typical times of 40 minutes for 99234, 50 minutes for 99235 and 55 minutes for observation code 99236. These periods include bedside care, review of additional studies, documentation and other cognitive services related to patient observational care. Admission/discharge codes 99234-99236 for same-day Medicare patients must include a minimum stay of at least 8 hours.

For less than 8 hours on the same day, the initial observation code series 99218-99220 is used for Medicare patients. In this case, discharge code 99217 is not used because the receipt and discharge took place on the same day of service. Like other services covered by Medicare, monitoring must be appropriate and necessary, i.e. medically necessary. The physician should document that he or she has assessed the patient`s risk to determine that the patient would benefit from observation services. Documentation should describe the risks that prevent the patient from being safely or returned home to a lower level of care, and how the patient would benefit from further observation in hospital. The documentation of this assessment forms the basis for the medical necessity of observation services. This is particularly important if the observation services are to be used as a basis later to reach the threshold of 2 at midnight – see below – as only medically necessary observations are taken into account to reach the reference point. Frequently Asked Questions 2. What is the total RVU for each of the observation codes compared to the ED codes? In addition to the order of observation, the documentation must demonstrate that the patient is in medical care. The Medicare Claims Processing Manual requires that notes at the time of enrollment and discharge, as well as other appropriate progress notes, be “timed, written, and signed by the physician.” The emphasis in the manual on the physician writing the progress notes corresponds to the requirement for assessment and reassessment in the definition of observation.

Assessing and reassessing a patient under observation ensures that the patient receives acute care and not just a lower level of care requiring care. Yes, with the addition of typical hours to the observation code sets 99218-99220, 99234-99235 and 99224-99226, they can now be used with extended service in the additional fixed or observation codes (99356 and 99357). For each CPT, use the codes listed below for observational care services provided on dates other than the start or exit date. It is unusual for observational care to require ≥ 3 days. These codes include the review of medical records and the review of the results of diagnostic studies and changes in the patient`s condition since the physician`s last assessment. Q1: The patient was admitted to the emergency room at 8 p.m., followed by observation at 2 a.m. (on the calendar date following the emergency department visit) and discharged later that day. A: Assign the appropriate ED-E/M code, 99281-99285, for the first day and the appropriate observation maintenance code, 99234-99236, on the second day. Do not assign 99217. Q2: The patient is admitted to the emergency department at 9 a.m., followed by admission for observation at 1 p.m. and then at 7 p.m. on the same calendar date.

A: Assign the appropriate observation code on the same day (99234-99236) for combined emergency/observation services. Do not assign 99217. (Note that there is no 8-hour threshold for CPT observation services.) For a Medicare patient with 6 hours of observation, codes 99218-99220 are used. Q3: What code should be reported on the middle day for a patient who is under observation for three calendar days? (Note: For Medicare, the patient must spend at least 8 hours under observation. See FAQ 8). Frequently Asked Questions 8. Looking at observation codes 99234-99236 on the same day, I found that Medicare requires a longer minimum stay in compliance status. It`s true? And what about commercial payers? Note: CMS said: “In most cases, the decision to discharge or hospitalize a patient after clarifying the reason for observational treatment can be made in less than 48 hours, usually less than 24 hours. Only in rare exceptional cases do significant and necessary outpatient observation services last more than 48 hours. But of course, 48 hours can extend over 3 calendar days. Extended stationary or observational code descriptors include: A patient presents to the emergency department with nausea, vomiting and diarrhea for 24 hours.

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